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Dementia is the leading cause of disability in people over 60 years old. Imaging is increasingly used to diagnose dementia to complement physical, cognitive and mental examinations.

Here, Dr Vanessa Newman explores the role of imaging in detecting this cruel and debilitating illness that effects over one million people in the UK.

Dementia: a global burden

Dementia is a leading cause of disability in people aged >60 years, representing a significant burden on patients in terms of quality of life, disability and mortality associated with the condition. This further impacts caregivers, health services and society in general. According to the World Alzheimer Report 2015, it is estimated there are 46.8 million people living with dementia worldwide and this number is due to double every 20 years. Of the 9.2 million people with dementia in Europe over 1.03 million live in the UK, representing a considerable health economic burden. Furthermore, general improved life expectancy of the global population is anticipated to correspond with increased prevalence of dementia.[1,2]

The impact of dementia on informal caregivers – such as family members and friends – is substantial and can result in physical and mental illness, social isolation and poor quality of life for them. Although their participation in the care of dementia patients may alleviate burden on healthcare systems and residential care homes, informal caregiving is not without societal costs caused by absenteeism from work.[2]

Different forms of dementia

Dementia is a progressive illness that affects not only a person’s memory but also their behaviour, mood, cognition and ability to perform daily activities. Progression of dementia is associated with both genetic predisposition and lifestyle factors, including smoking, alcohol, exercise and diet. There are a number of different dementia subtypes with varying incidence in the population, including vascular dementia (VaD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), Parkinson’s dementia (PD) and mixed dementia. However, Alzheimer’s disease (AD) is the most prevalent form, representing 62% of the dementia population.[3–6]

Diagnosing dementia

Although the majority of patients are diagnosed with dementia in later life, evidence shows that irreversible, pathological changes within the brain occur long before the onset of clinical symptoms. Gradual changes within the brain lead to progressive cognitive impairment and patients often experience a transitional period of mild cognitive impairment (MCI), during which a differential diagnosis may not be possible.[3,7–10]

Formal assessment of cognitive decline, as undertaken by dementia experts, usually includes physical, cognitive and mental examinations [e.g. the Mini Mental State Examination (MMSE)], plus a review of education and functional levels, medications and health history.[4,11]

Dementia assessment using brain biomarkers and structural imaging

There are several protein deposition biomarkers that may be used to assist in a diagnosis of dementing diseases, such as the presence of TDP-43 (FTD), Lewy bodies (DLB), alpha-synuclein (Parkinson’s disease), plus tau and β-amyloid which are typical in the pathogenesis of Alzheimer’s disease (although not exclusive to this dementia subtype).[12,13] Historically, reliable diagnoses might only be made post-mortem using histopathology. However, increasingly the imaging of biomarkers or their effect on the living brain can be made earlier on in the course of disease, before evidence of memory impairment is seen.[12,13]

Cerebrospinal fluid (CSF) sampling via lumbar puncture can help detect abnormal levels of soluble β‑amyloid42, total tau (T-tau) and phosphorylated tau (p-tau181), which may assist during the diagnostic workup of dementia patients being assessed for AD.[14] However, lumbar puncture is an invasive method and some patients may refuse the procedure or are contraindicated, for example, if they receive anticoagulant medications. In addition, CSF-based analyses show variability between immunoassay platforms and biomarker concentrations, which may present challenges to clinicians.[14–17]

Brain imaging in patients can assist a clinical diagnosis by examining presence of cerebral pathologies and structural changes, including MRI and CT that can detect subcortical vascular changes. Single-photon emission CT (SPECT) measuring perfusion can help differentiate AD, VaD and FTD,[4,11] while 2-(18F)Fluoro-2-deoxy-d-glucose positron emission tomography (FDG PET) may assist in detecting impaired neuronal activity by measuring the cerebral metabolic rate of glucose. This has been used to detect abnormal patterns in the brain and the potential to predict conversion from MCI to AD or the diagnosis of AD has been demonstrated.[8,9,18–20] Both SPECT-perfusion imaging and FDG-PET are indirect measures of disease that detect characteristic changes in glucose and oxygen metabolism. However, these imaging modalities show limitations in reflecting the aetiology of prodromal or mild AD.[8,9,11,19,20]

Brain β-amyloid (Aβ) deposition and plaque formation occurs early in the pathogenesis of AD, therefore offering the potential to assist in an early clinical diagnosis of patients being evaluated for Alzheimer’s dementia and other forms of cognitive impairment. Amyloid-PET is a relatively recent imaging modality and three 18F-labelled imaging agents are licensed for use in the EU that can detect the presence of β-amyloid neuritic plaques in the living brain, with validated visual assessment methods using histopathology as the standard of truth (Fig.2).[13,21] According to published appropriate use criteria, amyloid-PET is considered to have greatest utility in a subset of dementia patients:[22–24]

where there is an established persistent or progressive unexplained memory impairment (unclear diagnosis); or

where brain Aβ is a diagnostic consideration based on core clinical criteria, and where knowledge of this pathology may alter patient management; or

with progressive dementia and atypical age of onset (usually <65 years of age).

Fig 2: 18F-labelled imaging agents have the ability to detect the presence of β-amyloid neuritic plaques in the living brain (immunohistochemistry with monoclonal 6E10 Aβ antibody).[13]

Amyloid-PET does not alone provide a diagnosis, rather it forms part of the greater assessment workup by clinical experts, including neurologists, psychiatrists and geriatricians. The knowledge of the presence or absence of β-amyloid plaques has been shown to support a confident differential diagnosis and a tailored patient care plan, including use of medications where appropriate. There is also added value for patients and their caregivers in knowing the cause of dementia, enabling decision-making and planning for the future including the possibility of enrolling into clinical trials.[5,6,8,22–28]

The future of diagnostic imaging

The National Institute for Health and Care Excellence (NICE) is reviewing guidance on the organisation and delivery of diagnostic services, due for publication in August 2017. The scope of the revised guidance will encompass imaging in neurodegenerative diseases, as part of the wider radiology/nuclear medicine service in the NHS. This will affect not only patients, but all staff who use, refer and interpret diagnostic services in both primary, secondary and tertiary care.[29]

Vanessa’s background is in neurology (epilepsy and Down’s syndrome) and more recently in the field of neuroimaging in dementia. She has worked at Piramal Imaging since early 2015 and during this time has had the pleasure of seeing how quickly this area of medicine is moving, with increasing methods and imaging diagnostics available for use with people living with dementia.

Radiotherapy is an effective treatment for pelvic cancers but it is not widely known that the radiotherapy can affect healthy tissue and bone causing severe pain, incontinence and distress.

Here, Claire Poole explains what it’s like to have Pelvic Radiation Disease (PRD) and why she risked her life to raise money for the charity which has given her so much support.

Each year, in the UK, about 30,000 patients receive radiotherapy for pelvic cancers, half of whom are left with altered bowel and bladder functions that drastically impede a return to normal living. Symptoms of severe pain, nausea and vomiting, incontinence, damage to bones, gut/stomach issues can appear shortly after treatment, or months – even years – afterwards. Patients who report problems to their oncologists, surgeons and radiotherapists are often told that “We’ve cured your cancer so what’s the fuss about?. This response is common and also unacceptable. There are effective ways to manage late effects of pelvic radiotherapy (now recognised as PRD) and patients fortunate enough to get appropriate treatment report an average 70% improvement in symptoms.

Risking my life for PRDA

On Saturday 18th June 2016, I threw myself out of a plane at 15,000 ft. I harnessed my fearand put my life in the hands of the fantastic team at Go Skydive in Salisbury to do a tandem skydive, plummeting to earth at 125mph. I did this wacky thing to raise money for the Pelvic Radiation Disease Association (PRDA).

PRDA is a very small charity run by volunteers. The charity works so very hard trying to raise awareness of this condition among health professionals. PRD, the late effects of pelvic radiotherapy is not widely recognised by our own GPs or indeed the NHS. It has become a big part of mine, my partner, my two children, my family and friends’ lives.

I was diagnosed with cervical cancer four years ago, and had intense treatment consisting of chemotherapy, radiotherapy and internal radiotherapy. Thankfully, due to the treatment received I am still here, however, the radiotherapy treatment has changed my life. Yes it killed the cancer, but it also killed my insides.

Radiotherapy burns, it burns everything it touches. So while radiotherapy is highly effective in treating pelvic tumours, due to the nature of the treatment, it can affect tissues and other organs in the pelvic area. During my treatment not only were the cancer cells burnt and killed, but also all my healthy cells, tissues, bowel and bladder badly affected. Any cancer patient who receives radiotherapy to the pelvic area, will probably at some point experience the late effects of the cancer treatment. This could occur anything up to two to three years or longer after treatment. If this happens, as it did to myself and many other patients, we become unable to enjoy our cancer free lives. Our quality of life is hugely affected, from severe pain, nausea and vomiting, incontinence, damage to bones, gut/stomach issues. All of which can be either minor or cause you to be housebound or even hospitalised. All of which I have, and do experience.

I am a patient at the Royal Marsden and have been now for a few years. A very special man put me in touch with PRDA, a Dr Jervoise Andreyev. This wonderful man is a consultant gastroenterologist, who specialises in PRD and started PRDA. Dr Andreyev has made a huge difference to my life. Without the care of this man and his team, I would not be where I am today. I am not cured, but I am on treatments, have made lifestyle changes and I’m completing a medical trial. All with the help of Dr Andreyev, his team and PRDA.

Why did I raise money for this charity that many of you have never heard of?

I want to get PRD noticed and talked about and to publicise PRDA, to enable PRDA to help and support the thousands of other patients like me, who thought it was OK and normal, to have their quality of life taken from them just because they have had cancer. It is NOT OK. After all, we have fought so hard to beat cancer, surely we deserve to be given the best treatment and support possible, to try and live the rest of our lives happy and healthier with our families and friends?

Thank you so much for taking time in your day to read this. Please, please help me and others to raise as much money as possible to keep this wonderful charity going. To continue helping the thousands of brave, strong, beautiful women and men who need the support of PRDA in their lives”.

About the Pelvic Radiation Disease Association, (PRDA)

PRDA is a support organisation of patients, carers and medical professionals formed in 2007 became a registered charity in 2012 (no 1147802). We currently have 5 volunteer Trustees and 1 part-time self-employed Administrator. We publicise and increase awareness of PRD and provide support and advice to patients suffering from consequences of treatment. We inform and educate cancer nurse specialists, radiographers, oncologists, gastroenterologists, gastrointestinal surgeons, gynaecologists and urologists, about the symptoms and effects of PRD and provide clear and simple advice on how to refer patients for specialised help and treatment.

PRDA runs a telephone help line and an ‘email a nurse specialist’ advice service and are backed by a multidisciplinary team of experts to advise us on medical questions. Our website www.prda.org.uk provides support and advice for sufferers and we receive enquiries from around the world. The charity hosts support meetings covering such topics as diet, exercise, self-help, sexual health and radiography addressed by specialists on these topics – our aim is to provide help to enable people to cope better with the consequences of their treatment.

We present the charity’s work and objectives at major conferences throughout the UK via information stands and talks by patient ‘experts’ and have designed and produced literature for both patients and health professionals, working closely with other charities, particularly Macmillan Cancer support, Prostate Cancer, Beating Bowel Cancer, Bowel Cancer UK and Jo’s Trust (cervical cancer). These partnerships are essential to our work and together with Macmillan we chaired a Pan Pelvic Cancer committee of likeminded charities. In 2015 this resulted in a highly successful programme of training days for specialist helpline nurses from major cancer charities, an activity we strive to continue. We currently have an ongoing project in collaboration with Macmillan Cancer Support to list all gastroenterologists in the UK prepared to see patients with PRD.

PRDA has an active Facebook group with members both from the UK as well as other parts of the world, in particular the USA. This is a closed group and applications can be accepted via the PRDA website.

Professor Adrian Dixon has a worldwide reputation as an academic and a radiologist and has published extensively on body and musculoskeletal CT and MR imaging.

He will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

Read this fascinating interview with him and get a taster of this “not-to-be-missed” presentation.

You will be delivering the BIR Toshiba Lecture at UKRC this June. Your lecture is called “Has imaging become too effective?” Can you give us a “taster” of what you mean by this?

“You should say what you mean!” as the March Hare said in “Alice’s Adventures in Wonderland”.

What do people mean by “effective”? Effectiveness is only an appropriate term if qualified. Modern imaging certainly is effective at increasing the diagnostic confidence about a diagnosis and excluding certain diagnostic possibilities. It has taken a long while to prove that it is effective in saving lives. It has become so effective that, in many conditions, an image can be rendered to make the diagnosis obvious to the man in the street.

And clinicians now tend to refer for imaging without stopping to think! It has also become so effective in demonstrating probably innocuous lesions that the worried well can become even more of a hypochondriac! In some societies this can lead to over usage, excessive radiation exposure and increased costs.

If imaging is “too effective” – is radiology still a worthwhile career choice?

Yes! It is the most fascinating of all medical careers and every day a radiologist should see something that he or she has never quite seen before. The radiologist is the ultimate medical detective and cannot conceivably get bored. Indeed radiologists get reimbursed to solve crossword puzzles on elaborate play stations!

What have been the three biggest challenges for you in your career?

Radiologists have had to learn and relearn their skills at frequent intervals during their careers. Radiology will only survive as a specialty if the radiologist knows more about the images, the technical aspects and the interpretative pitfalls than their clinical colleagues.

Did you ever meet Godfrey Hounsfield (inventor of CT imaging) and what were your memories of him?

I did indeed meet Sir Godfrey on numerous occasions. His humility and “boffin style” of science greatly appealed. Some of the stories at the numerous events surrounding his memorial service were truly fascinating, including his inability to accept any machine which he could not understand without taking it to bits and then reassembling it!

Given the financial pressures on healthcare, will the required investment in the latest imaging technology be affordable?

Some of the developments in personalised medicine may be unaffordable. Generic contrast agents will continue to be used in large volumes. The cost of creating “one off” agents may prove unjustifiable.

Why would you encourage someone to join the BIR?

Because of the fun of interdisciplinary discussion and the pride of being a small part of the oldest radiological society!

Does spending more money on equipment mean a better health service?

I passionately believe that prompt access to imaging makes a major contribution to excellent healthcare. But that does not necessarily mean that every hospital has to have every machine at the top of the range. A rolling programme of equipment replacement is an essential part of delivering a high-quality radiological service.

The most difficult thing I’ve dealt with at work is…

An electrical power cut during the middle of a tricky adrenal CT-guided biopsy!

If Wilhelm Roentgen could time travel to Addenbrooke’s hospital, what would he be most impressed with?

The sheer size and the number of staff of the radiology department!

When its 2050, what will we say is the best innovation of the 21st century in healthcare?

Data mining and health statistics.

Who has been the biggest influence on your life? What lessons did that person teach you?

All my previous bosses have influenced my career. I have learnt something from each of them. All of them stimulated me to ask the question “why are we doing things this way”? “Can it be done better”?

My proudest achievement is…

Helping to make the Addenbrooke’s Radiology department one of the most modern in the UK.

What advice would you pass on to your successor?

Never give up, try, try and try again and remember “the more you practice, the luckier you get”.

What is the best part of your job?

That I have been lucky to have had a succession of challenges in the various roles that I have held, all of which have kept me on my toes.

What is the worst part of your job?

Leaving salt of the earth friends as I have moved from role to role.

If you could go back 20 years and meet your former self, what advice would you give yourself?

Do not worry so much – it will all be alright on the night.

Adrian Dixon

What might we be surprised to know about you?

That I support Everton Football Club.

How would you like to be remembered?

For influencing the careers of younger colleagues – hopefully to their benefit!

Professor Dixon will deliver the BIR Toshiba Mayneord Eponymous Lecture called “Has imaging become too effective?” at UKRC on 7 June 2016 at 13:00.

With a steady and sustained rise in imaging workloads driven by an ageing population, new and evolving technologies, and a drive for patient-focused care, radiology departments are turning to new ways to provide services. Nick Woznitza, Clinical Academic Reporting Radiographer at Homerton University Hospital, east London, and Canterbury Christ Church University, Kent, makes the case for radiology departments meeting these ever-increasing demands through radiographer reporting.

Using the example of his experience in the neonatal department of Homerton University Hospital he explains how, with robust research and training, and the appropriate use of skill mix, departments can offer a safe, efficient and patient-focused service.

Expansion of the neonatal medicine department at Homerton produced an increase in plain imaging workload and, coupled with a shortage of consultant paediatric radiologists, meant that the neonatal X-rays did not receive a timely definitive radiology report. The neonatal unit is a large, tertiary referral facility with 46 cots, 900 admissions and 13,600 cot/days per annum in 2013–2014. In order to provide an optimal service to these vulnerable patients, it was agreed to develop a radiographer-led plain imaging neonatal reporting service.

A bespoke, intensive training programme was designed in collaboration with radiology and neonatal medicine at Homerton, Canterbury Christ Church University and the paediatric radiology department of the Royal London Hospital. The radiographer was already an established reporting radiographer, interpreting skeletal and adult chest X-rays in clinical practice, so the training programme focused on the unique physiology and pathology of neonates. Training consisted of self-directed learning, pathology and film viewing tutorials, practice reporting, and attendance at the neonatal X-ray meeting at the Royal London Hospital. This immersive experience was achieved via secondment for one and a half days a week.
Upon qualification of the reporting radiographer, all reports were double read by a consultant paediatric radiologist, to successfully manage the transition into practice whilst maintaining patient safety in line with best practice recommendations.

To ensure that the performance of the trained reporting radiographer was comparable to that of a consultant paediatric radiologist a small research study was conducted (Woznitza et al, 2014), supported by research funding from the International Society of Radiographers and Radiographic Technologists (ISRRT). This study confirmed only a small number of clinically significant reporting radiographer discrepancies (n = 5, 95% accuracy), comparable to the performance of the paediatric radiologists. This study provided further evidence that the introduction of radiographer neonatal plain imaging reporting has not adversely impacted patient safety or care.

Activity figures (July 2011 – September 2014) were obtained from the radiology information system to determine the number of X-ray examinations performed and the proportion receiving a radiographer report. An average of 285 X-rays were performed each month, however, there was a marked increase in March 2012 from 158/month (July 2011 – February 2012) to 328/month (March 2012 – September 2014). The radiographer has made a sustained, significant contribution to the reporting service, interpreting an average of 92.5% of the X-ray examinations and responsible for >95% of examinations in 20 of the 36 months.

Building on the collaboration between radiology and neonatal medicine, a weekly neonatal X-ray meeting was introduced. Facilitated by the reporting radiographer and paediatric radiologist, this forum has increased radiology–clinician engagement and in turn patient care, facilitated discussions and acts as an excellent educational resource. Recognising the importance of this meeting, the senior neonatal clinicians requested that the reporting radiographer convene the meeting when the paediatric radiologist is absent on leave.

The introduction of a radiographer neonatal X-ray reporting service demonstrates that, with collaboration and support, novel approaches can help provide solutions to increasing activity in radiology in an effective, efficient and patient focused manner without compromise on patient safety. Collaboration and team work are fundamental when undertaking service delivery change. The support of both the radiology department, under the leadership of Dr Susan Rowe, and the neonatal unit, led by Dr Zoe Smith with mentorship from Dr Narendra Aladangady, has been essential in the success of this service.

Nick Woznitza biography
Nick qualified as a diagnostic radiographer from the University of South Australia and, following several roles in rural and remote Australia, moved to the UK in 2005.

An accredited consultant radiographer with the College of Radiographers, Nick reports a range of plain imaging examinations including skeletal, chest and neonatal X-rays. He has recently taken up a clinical academic radiography role at Homerton University Hospital and Canterbury Christ Church University, with this blended role facilitating image interpretation teaching to radiographers and other health professionals and his research into the accuracy and impact of radiographer reporting.

When Dr Chris Loughran published research into the benefits of trained radiographers reporting trauma radiology he was accused of committing professional suicide. But he was on a mission to spread the word.

Years ago I was appointed as Clinical Director of Radiology. I knew nothing about management and thought I had better go and learn something. I enrolled at Keele University for a diploma course in Management in Radiology. In the second year I had to write a dissertation. Scratching around for something I was inspired by Prof. Roger Dyson to consider what he termed “Clinical Radiography”, a concept that encouraged radiographers to move from the production of diagnostic images only to one where they also interpreted them.

Some research was essential and I was able to cajole three radiographers into contributing to the research effort. The aim was to determine if the diagnostic performance of the radiographers in trauma radiology could be enhanced with training, to such an extent that they could report such radiographs to a high standard. We showed that they could and the research findings were subsequently published in the BJR.1 We took the plunge even before the paper was published and with the backing of the East Cheshire NHS Trust those radiographers started to report directly to the accident department. I believe we were the first in the country to do this. The backing of the Trust Board was sought, and was essential, to ensure that in the event of error we were covered. It fulfilled my belief that radiographers could employ their talents to a greater extent—for the benefit of the department, the hospital in general and, of course, the patients.

I felt as though I was now on a mission—time to spread the word and encourage other departments to work in a similar fashion. To this end I decided to seek out further interest at a local regional radiologists meeting. Naively, I thought my proposals to expand our local in house training programme to a more established and regional exercise would be welcomed. Less time spent by radiologists on an element of the work that many were reluctant to undertake combined with better service delivery to patients seemed like an unbeatable combination. I should have known better! I had never been shouted down previously (nor since) but was that afternoon. “You’re committing professional suicide !” one colleague ferociously remarked, he’s probably forgotten, I never have. The idea clearly touched many raw nerves. So I slunk away, cowed, feeling battered and rejected. What I couldn’t really get my head round was the absolute rejection of the idea when I knew so many departments were struggling with their workloads and so many radiologists complained about it.

Despite this rejection the radiographers themselves picked up on the idea and I was asked by many organisations to speak about the research and the concept in general. I particularly remember one meeting in Nottingham where I spoke to a crowded lecture theatre. I was introduced by a radiologist, the talk went well and he very kindly remarked afterwards that I was so convincing he would buy a second hand car from me!

Later I was invited to help establish a course in radiographer reporting at Canterbury, Christ Church College. We agreed a schedule for the course and associated examination. I was privileged to be an external examiner and was mightily impressed by the very high standard that many candidates attained. Radiologists had (until then) never been examined in trauma plain film radiology to the extent these candidates were.

Of course, similar training soon followed elsewhere and it now is established practice in many departments. Indeed it has gone further with radiographers reporting other examinations including CT head scans, for example. Moreover, many adverts for radiologist positions now highlight this practice as an inducement for candidates to apply for their posts. Its moved a long way since that regional radiology meeting all those afternoons ago.

Its taught me that its not only the truth that matters but also the diligence with which it is pursued. If you believe in something keep going! As Edward Bulwer-Lytton put it, “Enthusiasm is the genius of sincerity and truth accomplishes no victories without it”.

I qualified in Liverpool in 1976 and have been pursuing radiology since 1978. I trained in radiology in Liverpool. After a 2-year stint as Consultant at Broadgreen Hospital I went to the USA for a year where I was Assistant Professor in The Medical University of South Carolina, Charleston, USA. Returning to England I took up post in Macclesfield where I have been since 1986.

In my time I have been Clinical Director, Postgraduate Tutor, Associate Medical Director and Chairman of the Medical Staff Committee. I was Chairman of the Northern Branch of the BIR and BIR council member some years ago. Now I work as a clinical radiologist and am so lucky that I still enjoy the speciality as much as I did all those years ago.

Unlike most NHS Acute Trusts, who tend to have large static diagnostic imaging departments located around a single or a small group of hospitals, private diagnostic imaging providers tend to have numerous static locations, a central patient management centre and varying fleet sizes of mobile scanners that move around on a daily basis. Private diagnostic imaging providers also have to contend with varying requirements from their customers that include scan-only services, book-scan-and-report services, or even report-only services. Service levels vary from customer to customer and the actual process of managing a patient differs between NHS, self-pay, medical insurance and medico-legal customers.

This variability highlights the fact that any clinical system deployed within a private diagnostic imaging provider needs to be able to cope with different workflows within the same location. It also implies that the clinical systems need to manage the end-to-end patient pathway in a manner that is completely separated from a fixed geographical location, as different parts of the patient pathway can take place in different locations. An example of this is where a patient calls the patient management centre to make a booking, the scan takes place at one of the scanning locations and the clinical report is completed by a tele-radiology provider. The clinical systems should therefore understand the concept of a workflow and a distributed network of scanning locations, as well as have the ability to move information seamlessly among various locations in accordance with the desired pathway.

The customer base of a private diagnostic imaging provider also varies from a commercial perspective. There are significant differences in customer requirements for management information, payment calculations and billing processes. This is on top of more intricate billing requirements such as factoring, zero-rated VAT or VAT exempt treatments that apply to some, but not all customers.

The realities of a business built up over time
Some of the private diagnostic imaging providers in the market started out in the pre-digital era and in the early days most diagnostic images were captured, stored and reported based on film. Over time RIS and PACS clinical applications appeared and of course private diagnostic imaging providers adopted these as appropriate. Since these technologies were still in their early phases of development, the designs tended to reflect the limitations in technology at the time and it was focussed on serving the needs of specific contracts. Some of these providers also grew by acquiring other smaller companies with their own legacy systems in situ.

These contributing factors typically result in a variety of RIS and PACS applications installed in the same organisation, all of which serve different purposes, different contracts and manage different parts of the patient pathway. To any manager the obvious implications of this scenario are, amongst others, large management overheads, a high degree of complexity in the technology solutions, various manual processes and an inability to rapidly change to accommodate customer needs.

Procuring a single RIS-PACS

To move from a situation where there are multiple RIS and PACS applications in place to a single unified system carries some significant challenges. Engrained manual business processes, distributed staff locations, radiologist availability and varying customer expectations are all significant challenges to overcome and manage. This is not even talking about the technical and logistical issues that a project of this nature would face.

Understanding the customers’ needs must form the core of any such change process and this must be layered on top of the requirements from the relevant operational teams. One of the key decision points in the design and deployment of a unified RIS-PACS environment is the balance that needs to be struck between flexibility and standardisation.

The flexibility within the system to accommodate operational needs and customer requirements is very important for any commercial organisation. On the other hand it is no use accommodating different customer requirements if these cannot be delivered to a consistent level of quality and to a consistent service level. Although there is a degree of overlap, these two system properties tend to be opposing forces in terms of the demands they place on a clinical systems platform. A good balance can only be achieved through proper engagement with customers and the relevant operational teams.

The procurement of a RIS and PACS system, at least from a private diagnostic imaging provider’s perspective, needs to fulfil several criteria and these include:

• It must have an integrated billing engine that can cope with all the requirements from different customers.
• It must manage the entire end-to-end patient pathway in the absence of a hospital information system (HIS), which includes multiple inbound channels and multiple outbound channels.
• It must allow for different workflows to be accommodated within the same clinical application that is a specific property of the contract associated with the patient.
• It must understand and cope with a distributed network of scanning facilities, some of which are static and some of which are mobile.
• It must allow for electronic interfaces and for the integration of any new developments to take place in a consistent way that is easy to manage.
• It must allow the private diagnostic imaging provider to change and configure the system as an inhouse function and not one that requires vendor intervention to the degree it is prevalent today.
• It must accommodate different clinical workflows that include scan only, scan and report, report only, double reads, report audits and also remote reporting.

This list is not meant to be comprehensive, but it is intended to highlight the requirements that a private diagnostic imaging provider will view as essential, as opposed to most radiology departments within a hospital setup. This set of criteria does point out the fact that most of the incumbent RIS vendors, and to a lessor extend the PACS vendors, do not meet all the criteria. It is therefore inevitable that some degree of customisation and development will be required for any clinical systems platform to be successful.

The implementation process
Once the appropriate systems have been procured, attention needs to turn to the implementation process. It goes without saying that a formal project methodology must be followed to have any hope of a successful implementation. Instead of providing an account of all the formal elements that a project of this nature requires, we would rather want to share our experience of the top four learning points:

• Change: with any new system, there will be an element of change. The obvious example is the fact that staff members will be using a different clinical system to manage their daily workloads. There is however several areas of change that often get overlooked in a project of this nature. These include items such as the mechanism for how radiographers can move an image from the scanner to a specific radiologist. This is a simple task, but one which is core to the operation of any diagnostic imaging unit. The overall system might work very well, but if the key tasks that staff members need to perform on a daily basis are overlooked then it is easy to undermine the success of the entire project.

• Process standardisation: implementing a single unified RIS and PACS implies that the same business process will be followed at each location. To assume that each scanning unit operates in exactly the same way will be a mistake though. Local business processes will have evolved over time and are a function of location-specific factors, customer-driven preferences, individual staff influences and of course head office standard operating procedures (SOPs). There must be a high degree of focus on ensuring business processes are standardised at each location, in order to accommodate a single RIS and PACS application. Deploying a system that enforces a standardised business process on a business environment that operates in a variety of ways, has the potential to stall the entire project.

• Communication: with a workforce scattered around the country and a large proportion of it serving a mobile fleet, it is no surprise that communication is one of those tenacious challenges that needs constant attention. No single communication method will suffice in this situation and it is up the project team to use any and all means available to ensure the relevant messages reach the correct target audience. These methods can include anything from formal letters, face-to-face meetings and even social media. Social media is of course playing an increasingly important role in most people’s daily lives and it is a very useful tool in the business environment as well. External stakeholders need to be included at the appropriate times.

• Coordination: the nature of most private diagnostic imaging providers is such that different parts of the patient work flow can take place at different locations. The payer of the service is mostly the determining factor that dictates which element needs to take place where. This is however a moving feat for the simple reason that patients from multiple contracts can be scanned at any scanning unit. The respective units therefore need to cope with different contract workflows at different times throughout the day. The implications for implementing a RIS and PACS as a unified platform is therefore that it is easy to undermine the company’s ability to service a patient if the implementation of all the different supporting systems are not well coordinated.

Conclusion
The latest technologies around work flow management will allow most private diagnostic imaging providers to improve productivity as well as quality at the same time, but it is important to realise that any project of this nature and scale requires just as much energy to manage the business change process as it requires to change the technical system. Even though the journey to a single RIS-PACS platform might have its challenges, it is our firm opinion that the benefits far outweigh the costs and the risks.

About Dr Johann Alberts

Dr Alberts is a qualified medical doctor and his main clinical experience is in emergency medicine, both in the UK and South Africa. his experience includes private, public and military healthcare systems. In 2007 he made a career choice that deviated away from clinical medicine towards healthcare management. His passion is to design and implement healthcare services to ensure that more patients can benefit from what is already a scarce resource.

After completing an MBA at Oxford University, Johann joined BMI Healthcare as a Programme Director, where he managed four divisions that included Physiotherapy, Health Screening, Speech and Language Therapy and Occupational Health.

Johann joined Alliance Medical in 2012, first working at group level designing a quality strategy, implementing benchmarking and assisting on various projects around the company. At present Johann is directing the RIS-PACS implementation project, which will be completed in early in 2015.

Lead Radiographer Jeanette Snowden, from Derriford Hospital, talks about the impact of delivering a BIR accredited radiation protection course at Kitale Hospital, Kenya.

There are many charitable organisations quietly delivering fantastic projects around the world with little fanfare. EGHO (Exploring Global Health Opportunities) and MEAK (Medical and Educational Aid to Kenya) work together to improve health in Kenya, focussing on trauma and orthopaedics, patient safety, hospital staff education and training, and community health. The aim is to teach and leave a legacy of education.

In April 2013 I was approached by EGHO, who wanted an imaging service delivered to theatres in Kitale District Hospital, West Kenya, which was new to the project. The hospital required an image intensifier (II) and an educational package, and the trip was planned for November 2013. My imaging department donated a II, which was collected and whisked into a container for its lengthy sea-bound journey within a week. The educational package required a bit of thought; I have been teaching radiation protection (RP) for a number of years to many professions, and I know it’s not the sexiest of subjects to teach– it does not have the attributes of, for example, ED trauma education, which can be dressed up with graphic photos and adrenaline. However, RP is essential training.

Listening to the experiences of radiographers who had provided imaging back up on previous orthopaedic EGHO trips to other Kenyan hospitals, I realised there was little interest from the local radiographers to continue the theatre imaging service once the project had returned to the UK. The image intensifier remained dormant, restricting the scope of surgical procedures and directly affecting patient care. However, I discovered that accredited courses with a certificate are held in very high regard within the Kenyan working community. Engaging the local radiographers and the theatre staff in the safe use of the II and RP was essential to the delivery of the project, and I believed a certified course, accredited by the BIR, would be the key to its success. With the support of the Clinical and Radiation Physics department within my Trust, and Andy Rogers, Vice President (External Affairs) at BIR and Head of Medical Physics at Nottingham University Hospitals Trust, I wrote a RP course, to include a practical session for the radiographers, an exam, safety signage and the all-important certificates. Rather brilliantly, the BIR accredited it.

The journey from the UK to Kitale took a slightly-longer-than-expected 36 hours, but the reception we received from the staff couldn’t have been more welcoming. The UK team arrived with over 30 cases of donated kit, and the staff set about finding storage in the fairly limited facilities. Nothing was too much trouble. The donated II had spent four months languishing on the docks in Mombasa awaiting Kenyan authorisation to travel to West Kenya, and to our relief was given the stamp of approval just after we arrived in Kitale. I spent a day travelling to collect it with a truck and a driver, and our return caused quite a stir – I had not known that this intensifier was only the second one in the whole of West Kenya – no one had seen one before, let alone know what it was capable of! Much to my amazement, given the journey it had just undertaken and how ‘temperamental’ they can be, the II worked the moment I switched it on. We were all set to go.

I delivered the RP practical training over a few days, given the space restrictions of theatre, but the Powerpoint presentation was attentively received by 23 candidates (3 radiographers, 15 doctors and all of the theatre staff), all crammed into a tiny staff room at 8.30am. I tested their prior and post-course knowledge, and am happy to report that all candidates significantly improved their RP knowledge. Practical training occurred during operative sessions, where all staff complied with the signage, maintenance of Controlled (Restricted) Area, and wearing of PPE. And-the theatre Charge nurse adopted the responsibility of supervising the area after the team returned to the UK. I trained a senior radiographer, Mr Okumu, in the specific use of the image intensifier.

Franklin’s femur before surgery

I cannot over emphasise the delight with which the imaging equipment was received by the local staff, nor the impact that it has already had on patient care. Franklin was one of our patients who had been on the orthopaedic ward in Kitale for over three months with a fractured femur, sustained during a motorbike road traffic collision. He had stones tied to his leg to act as traction. He told me he thought he was going to die in that bed.

Franklin’s femur post-surgery

Using the II for guidance, the UK team were able to teach the local general surgeons how to implant a sign nail into Franklin’s badly-fractured femur. On our final ward round, we saw Franklin putting weight through his leg; a massive grin on his face, singing and high-fiving everyone in the team. He said we had saved his life.

Kitale District Hospital now has an imaging service in theatre, delivered by local professionals who have completely engaged in education accredited by the BIR.

Through this experience I have learnt a great deal, not least to truly appreciate, and not take for granted, the undeniable volume of work that has resulted in the high level of safety and the high quality healthcare system that we have in the UK. Jeanette is due to return to Kenya in April 2014.

About Jeanette Snowden, Lead Radiographer for Theatre and Mobile Imaging at Derriford Hospital.

I look after over 35 theatres and 40 wards, including 4 critical care wards, and I am RPS for the whole area. I teach radiation protection at both Plymouth and Exeter Universities, to the student radiographers and to all amenable staff at Derriford! I love my job, and believe that every quality improvement should have a direct impact on the care that we give to our patients.